| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
557 |
557 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
235 |
234 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
46 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
131 |
116 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
708 |
706 |
$3K |
| D1351 |
Sealant - per tooth |
166 |
46 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
13 |
$3K |
| D1120 |
Prophylaxis - child |
864 |
862 |
$599.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,855 |
689 |
$340.78 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$145.68 |
| D1208 |
Topical application of fluoride, excluding varnish |
739 |
736 |
$67.00 |
| D0272 |
Bitewings - two radiographic images |
170 |
169 |
$61.00 |
| D1330 |
|
872 |
869 |
$3.00 |
| D1999 |
|
97 |
93 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
82 |
82 |
$0.00 |